U.S. Simulation of Lifetime Major Depressive Episode Prevalence and Recall Error

Abstract

Introduction: Simulation models can improve measurement and understanding of mental health conditions in the population. Major depressive episodes are a common and leading cause of disability but are subject to substantial recall bias in survey assessments. This study illustrates the application of a simulation model to quantify the full burden of major depressive episodes on population health in the U.S.

Methods: A compartmental model of major depressive episodes that explicitly simulates individuals' under-reporting of past episodes was developed and calibrated to 2005-2017 National Surveys on Drug Use and Health data. Parameters for incidence of a first major depressive episode and the probability of under-reporting past episodes were estimated. Analysis was conducted from 2017 to 2019.

Results: The model estimated that 30.1% of women (95% range: 29.0%-32.5%) and 17.4% of men (95% range: 16.7%-18.8%) have lifetime histories of a major depressive episode after adjusting for recall error. Among all adults, 13.1% of women (95% range: 8.1%-16.5%) and 6.6% of men (95% range: 4.0%-8.3%) failed to report a past major depressive episode. Under-reporting of a major depressive episode history in adults aged >65 years was estimated to be 70%.

Conclusions: Simulation models can address knowledge gaps in disease epidemiology and prevention and improve surveillance efforts. This model quantifies the under-reporting of major depressive episodes and provides parameter estimates for future research. After adjusting for under-reporting, 23.9% of adults have a lifetime history of major depressive episodes, which is much higher than based on self-report alone (14.0%). Far more adults would benefit from depression prevention strategies than what survey estimates suggest.

Figure 1.

Model diagram of depressive states and transitions. MDE, major depressive episode; Diamond, annual probabilities estimated during model calibration; Never MDE, individuals with no lifetime history of MDEs; Past year MDE, individuals with a past year MDE; Former MDE, individuals with lifetime history of at least one MDE but no MDEs in the past; Recall error, individuals who report no lifetime history of MDEs but are modeled as former MDE.

Figure 2.

Annual probability of first major depressive episode. Notes: Solid line = Females ages 12–21 years calibrated model estimates; Dashed line = Males ages 12–28 years calibrated model estimates; Black dots = incidence probabilities for female age at onset of major depressive disorder (MDD) in the Baltimore Epidemiological Catchment Area (ECA) Study; Circles = incidence probabilities for male age at onset of MDD in the Baltimore ECA Study.

Figure 3.

Past major depressive episode under-reporting probabilities by age. Notes: Solid line = Females; Dashed line = Males; model estimates calibrated for age groups 18–25, 26–34, 35–49, 50–64, and ≥65 years. Annual probabilities for individuals age <18 years fixed at zero.

Figure 4.

Adult lifetime MDE prevalence by age group with recall error adjustment, 2017. Notes: Distribution of the adult population with past year MDE (black), former MDE (gray), former MDE with recall error (diagonal hatching pattern), and never MDE (white). Numbers represent the percent of individuals with lifetime MDE histories. Numbers in parentheses represent the percent of individuals with recall error who fail to report lifetime MDEs. MDE, major depressive episode.